Novel Calculator Guides Treatment Choice in Esophageal Cancer

A novel calculator can more easily identify which esophageal adenocarcinoma patients derive an overall survival benefit from neoadjuvant chemoradiation to help guide treatment choices, according to a new study.

Neoadjuvant chemoradiation is established practice for esophageal adenocarcinoma patients with locally advanced and/or node-positive tumors. The challenge for clinicians is to determine which esophageal cancer patients will derive benefit from neoadjuvant chemoradiation, which can lead to either a pathologic complete response or to persistent or even progressive disease.

Up to 70% of patients will be downstaged as a result of neoadjuvant chemoradiation, stated the researchers, led by Emmanuel Gabriel, MD, PhD, of the department of surgical oncology at Roswell Park Cancer Institute in Buffalo, New York. However, some patients do not benefit and neoadjuvant chemoradiation may even result in higher mortality.

Tools to predict which patients derive the most benefit from neoadjuvant chemoradiation “would therefore have much needed utility in the treatment of esophageal cancer,” they stated.

Using calculators to estimate outcomes and apply the results to real-time clinical situations can aid in treatment decision-making and to individualized therapy, they noted.

“Our effort is a good example of how you can use large national databases to create calculators to guide and improve preoperative decision-making. Such tools can help us, for example, to avoid the toxic side effects of upfront chemoradiotherapy in a subset of patients,” said senior author Moshim Kukar, MD, assistant professor of surgery in the department of surgical oncology at Roswell Park.

The researchers set out to create a tool to help identify which patients may benefit from treatment before surgery, noting that patients with advanced, aggressive tumors are often good pretreatment candidates.

They published their results online in the Journal of the American College of Surgeons.

Using the National Cancer Data Base, the researchers evaluated clinical data for 8,974 patients diagnosed with early-stage esophageal adenocarcinoma. The database records information for as many as 70% of the nation’s cancer cases through participating hospitals. They evaluated characteristics such as patients’ comorbidity score, tumor grade, and neoadjuvant chemoradiation status (whether they had chemotherapy and/or radiation prior to surgery).

To develop the calculator, they used preoperative data only.

The results show that those who received neoadjuvant chemoradiation had improved overall survival. The patients who benefited more from neoadjuvant chemoradiation included those whose tumors had metastasized to nearby lymph nodes, older patients and those with more aggressive cancers, such as tumors of higher grade and greater depth of invasion.

The researchers stated that “we developed an individualized overall survival calculator for esophageal adenocarcinoma that shows reasonable performance in identifying subsets of patients who would most benefit” from neoadjuvant chemoradiation.

Kukar noted that the “calculator should be validated prospectively before firm conclusions can be drawn about its value in treatment selection.”

The researchers plan to compare their calculator with the few existing calculators and to refine their prediction models as updated and more contemporary data are released from the National Cancer Data Base.